Every finding on record at Charter Hospice of Colton, LLC

Observed in Record Review. In 7 of 13 patient records reviewed, During RR#1, RR#2, RR#3, RR#4, RR#5, RR#6 and RR#10 it was noted although the IDG met no less frequently than every 15 days, there is lack of documentation that the Chaplain participated in the update of the comprehensive assessment during IDG meetings. During RR#3 it was noted at the IDG meeting the end of May lack of an update to the comprehensive assessment by the MSW. The portion of the IDG meeting summary for medical social services is blank. During RR#3 it was noted on a triage note the middle of April: spouse reports pt. is having unrelieved pain , medication has been ineffective. Advised to administer 1 ml of morphine as ordered. Verbalized understanding by repeating name of medication and dosage. Nurse to assess. The clinical finding of increased pain was not documented at the IDG 2 days later. The POC was not updated to reflect this change and assess pain medication effectiveness. During RR#5 it was noted on the SN note the middle of May 2022 that the stage 2 pressure ulcer wound was resolved. The IDG 6 days later was not updated to reflect the wound was healed. During RR#6 it was noted an order for Flagyl the end of April 2022 due to green odorous diarrhea documented on an SN note. The POC was not updated to reflect new medication and the change in the GI status. The findings were discussed with the DPCS.

Observed in Record Review. In 2 of 13 patient records reviewed, During RR#1 it was noted the patient record lacked accurately documented SN notes. An SN visit in May 2022 documented the patient had a wound on the left foot which was inconsistent with SN documentation before and after that visit that documented the wound was a skin tear on the left knee. An SN note in April documented Metformin 1000mg 1 tab twice daily for diabetes, hum along kwikpen 10 ml tree times daily with meals. In discussion and review with the DPCS, the documentation by the SN of 10 ml was an error instead of 10 units. During RR#5 it was noted an order to D/C the oxygen in November 2021. During subsequent recertification periods the oxygen was not reordered and was not on the medication profile. The recertification RN assessment documented oxygen at 2L/min PRN in February 2022 while the oxygen safety assessment documented no oxygen in the home. SN notes intermittently from March 2022-the beginning of June 2022 document oxygen at 2LPRN SOB. The RN recertification comprehensive assessment in April 2022 and the oxygen safety assessment, documented no oxygen in the home. The SN note the end of May under the pain assessment section documented the patient was taking Norco, acetaminophen 500 mg for pain management. The medication profile did not list Norco or Hydrocodone/acetaminophen as a current medication. Lidocaine patches were discontinued via an MD order the end of April 2022 and was documented as discontinued during an IDG meeting the beginning of May 2022. Intermittent SN notes in May 2022 documented the patient's daughter was applying Lidocaine patches. The findings were discussed with the DPCS.

Observed in Record Review. In 13 of 13 patient records reviewed, During RR#1, it was noted the deficits/problems identified in the POC that included psychosocial, pain, respiratory, endocrine, emotional issues had the same proposed goal accomplishment dates that were the next IDG meeting date. The goals were updated at each IDG with the accomplishment date changed to next IDG meeting date. During RR#2 it was noted the goals at the recertification were the same as the firs certification with end dates changed to the most current IDG. For example the goal of Emergency plan will be established by: 5/24/2022. The goal was established during the first certification and second certification to date without documentation of issues to accomplish the goal. RR#3 and RR#4 had the same goals in first and second certification with end dates to be achieved every 2 weeks and changed to the next 2 week period after each IDG. During RR# 5-10 and HV#1-3 record review, it was noted goals remained the same and were updated to the next IDG meeting date every 2 weeks through certification periods. This was discussed with the DPCS.

Observed in Record Review. In 4 of 13 patient records reviewed, During RR#1 it was noted during the SN the end of March documentation that the patient reports … is having pain to his right great toenail... Toenail appears ingrown. New order for epsom salt soaks once daily for 20 minutes. The order with the identification of the problem, interventions and goals were not added to the POC at the IDG the beginning of April 2022. An order for wound care to a skin tear on the right knee the middle of May 2022 with interventions and goals were not added to the POC at the next IDG meeting the beginning of May 2022. The order stated cleanse with normal saline, pat dry, apply triple ointment antibiotic daily for 7 days and reassess. The intervention order lacked if the family was to be instructed on the wound care procedure as the SN frequency was not increased to perform the care. An order for insulin to be administered via a sliding scale the beginning of April lacked documentation to indicate if the patient/family were proficient in injection technique, when to perform blood sugar checks, and disposal of sharps. During RR#2 it was noted documentation of an order for wound care to the left upper arm: Wound #1 Left Upper Arm Skin Tear 1.5 cm x 1 cm cleanse with normal saline, pat dry, apply triple antibiotic daily, x 14 days then reassess. The skin tear problem was not added to the POC at the next IDG meeting to include interventions and goals. During RR#3 it was noted an order for a urinalysis due to malodorous urine with c/o dysuria and frequency along with an order for Macrobid for 3 days. The POC was not updated to include the GU problem with interventions and goals. During HV#2 record review it was noted a volunteer assignment documented with a frequency of 2 times/month. The discipline, frequency, interventions and goals were not added to the POC at the next IDG meeting the end of March 2022. Volunteer services was not added to the POC until the middle of April 2022. These findings were discussed with the DPCS.

Observed in Record Review. In 1 of 13 patient records reviewed, During RR#2 it was noted a frequency on the POC for the MSW, 1X's/month and 1X's/week as needed for psychosocial support. There is lack of documentation of a visit attempted or completed in April 2022. This was discussed with the DPCS.

Observed in Record Review. In 1 of 13 patient records reviewed, During RR#2 it was noted the beginning of May 2022 an order to remove the suction machine per patient/PCG request. The recertification POC equipment list was not updated and the suction machine remained on the POC. The findings were discussed with the DPCS.

Observed in Record Review. In 2 of 13 patient records reviewed, During RR#1 it was noted an order for blood glucose checks 3 times per day. There was one SN notes from March 2022 to May of 2022 that had documentation of blood sugar results. The documented result did not indicate when the test was done. During RR#2, the following order for wound care the middle of May 2022 was: Wound #1 Left Upper Arm Skin Tear 1.5 cm x 1 cm cleanse with normal saline, pat dry, apply triple antibiotic daily, x 14 days then reassess. The 2 SN visits after the order was written at the end of May 2022 lacked an assessment of the skin tear or documentation of the wound care.

Observed in Infection Control Tracer. The organization's written infection prevention and control plan lacked a goal that included limiting unprotected exposure to pathogens. This was discussed with the DPCS and the QAPI Coordinator. Observed in Infection Control Tracer. The organization's written infection prevention and control plan lacked a goal limiting the spread of infections associated with procedures. This was discussed with the DPCS and QAPI Coordinator. Observed in Infection Control Tracer. The organization's written infection prevention and control plan lacked a goal that included limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was discussed with the DPCS and the QAPI Coordinator.

Observed in Record Review. In 6 of 13 patient records reviewed, During RR#1 it was noted the aide assignment form lacked under special instruction, oxygen use (specify) the order for oxygen therapy included on the POC. Oxygen safety was checked off within the safety precautions section of the assignment. RR#3, RR#7, RR#9 and RR#10 aide assignment form lacked the oxygen order as part of the special instruction, oxygen use (specify) on the assignment form. This was discussed with the DPCS. During HV#1 it was noted during the home visit the aide removed the protective barrier on the patient coccyx during the bath in June 2022. The aide assignment form lacked direction to the aide to remove the protective barrier and replace. This was discussed with the DPCS.